Ask Our Doctors – Archive
Our Medical Directors are outstanding physicians that you will find to be very personable and compassionate, who take care to ensure that you have the most cutting-edge fertility treatments at your disposal. This is your outlet to ask your questions to the doctors.
Hi Dr Sher-
So i had IVF, my hcg levels were 74 then 282 then 604, had ultrasound at 5 weeks 5 days they said was good saw gestational sac and yolk sac and measuring correctly. But went to 2nd ultrasound 7 weeks, and doc said it didn’t grow much measuring at 5 weeks 5 days but he still wants me to continue my meds estrace (estrogen pills 2pills 3x a day and progestrone injection daily at nights) and come back in 2 weeks for ultrasound again (will be 9 weeks)
I’m very confused, if it doesn’t seem good unfortanatlety then why am still taking the meds? And if I continue taking meds wouldn’t it stop me delay from getting period or bleeding or miscarriage. Or will that happen regardless of taking meds? I feel nothing no symptoms, Is there anyyyy hope.. Please help.
Hi Ann,
Your doctor is playing safe…to determine with certainty as to how the pregnancy will go. I agree with this cautious approach!
Geoff Sher
Bonjour,
Suite à mes échecs d’implantation avec des embryons top qualité, mon médecin m’a prescrit des perfusions d’intralipides 20% 100ml à diluer dans dans 400 ml de Na CL 0,9%.
Je suis installée au Maroc et les intralipides 20% n’y sont pas commercialisés.
Le seul produit disponible avec les lipides est le Periolimel N4( compartimenté avec 400 ml de d’emulsion lipidique contenant 60g de lipides dont 20% uniquement de huile de soja ).
Mon médecin traitant et mon pharmacien n’ont pas idée comment utiliser le Periolimel à la place des intralipides.
Je vous prie de bien vouloir m’indiquer le dosage utiliser le Periolimel N4 ( le compartiment lipidique) pour le substituer aux intralipides 20%.
Je vous remercie par avance.
Please re-post in English and I will gladly respond promptly!
Geoff Sher
Hello doctor, this is Deniz. I am 32 years old. I suffer from endometriosis and my ANA test came back positive. I tried 5 Frozen Embryo transfer with good quality embryos but 4 of them never imlanted and 1 early miscarrige. Contrary to my doctor, I believe thar this is an immune issue. For my sixt transfer I want to try prednisone and clexane but I do not know when to start and the dosages. Based on my research, I understand that I should start prednisone 8-10 mg 10 days prior to FET and make it 16-20 mg following on the day of transfer and start clexane on transfer day. Does it make sense? If I knew how I should proceed further, I can discuss the alternatives with my doctor. Looking forward for your reply. Many thanks in advance, Deniz.
I strongly advise that before you consider taking meds for a possible immunologic implantation dysfunction, the the underlying immunopathology be identified throu=gh appropriate testing.
Central to making a diagnosis of an immunologic implantation dysfunction (IID) is a need for the appropriate interpretation of Natural Killer Cell Activity (NKa). In this regard, one of the commonest and most serious errors, is interpret the blood concentration of natural killer cells as being relevant. Rather it is the activity (toxicity) of NK cells that matters as mentioned. This activity can best be measured using the blood, K-562 target cell test (the gold standard). and/ or endometrial biopsy for cytokine activity.
With the K-562 test, the most important consideration is the percentage of target cells “killed” in the “native state”. In most cases a level of >10% killing should be regarded with suspicion and >12% overtly abnormal. In addition to reporting the result of the K-562 test, in the “native state” (without adding, Immunoglobulin-G (IVIG) or Intralipid (IL) which many Laboratories erroneously do to try and determine whether either or both of these immune therapies would have a therapeutic benefit or is/are unlikely to be of clinical value. The entire premise upon which this assertion is based, is in my opinion flawed. Clinically such NK cell deactivation can only be significantly affected in vivo as it takes more than a week following infusion to occur. Thus, what happens to the percentage of target cells killed with the K-562 test, by adding IVIG or IL is in my opinion irrelevant
Another way to assess endometrial NKa is by measuring TH-1 and TH-2 cytokines in endometrial tissue derived through biopsy.TH-1 cytokines kill the trophoblast (the root system of the embryo). Thus if is an excess of TH-1 cytokine activity is found with/without a disruption in the TH-1: TH-2 ratio, this points to NK cell activation.
There are basically two causes of immunologic implantation dysfunction (IID), a) Autoimmune (85%) & , b) Alloimmune (15%). The former occurs when the body reacts to its own tissue and the latter (far less common) when the male and female partners share certain genotypic similarities involving DQ alpha and HLA genes. In both cases IID results in rejection of the pregnancy due to uterine Natural Killer (NK) Cell and T-cell activation leading to the release of an excessive amount of TH-1 cytokines. These, “toxins” attack the embryo’s root system (trophoblast), killing the cells and causing implantation to fail.
Autoimmune Implantation Dysfunction: Autoimmune implantation dysfunction, most commonly presents with presumed “infertility” due to such early pregnancy losses that the woman did not even know she was pregnant in the first place. Sometimes there as an early miscarriage. Tests required are: a) blood levels of all IgA, IgG and IgM-related antiphospholipid antibodies (APA’s) directed against six or seven specific phospholipids, b) both antithyroid antibodies (antithyroid and antimicrosomal antibodies), c) a comprehensive reproductive immunophenotype (RIP) and, c) most importantly, assessment of Natural Killer (NK) cell activity (rather than concentration) by measuring by their killing, using the K-562 target cell test and/or endometrial cytokine activity tests.
It is important to recognize that currently there are only about 3 or 4 Reproductive Immunology Reference Laboratories in the U.S.A that, are capable of reliably analyzing the required elements with a sufficient degree of sensitivity and specificity. I use a Reprosource, a laboratory located in Boston,MA.
Patients with Alloimmune implantation Dysfunction usually present with a history of unexplained (usually repeated) miscarriages or secondary infertility (where the woman conceived initially and thereupon was either unable to conceive again or started having repeated early miscarriages. However, it can also present as “presumed” primary infertility. Alloimmune dysfunction is diagnosed by testing the blood of both the male and female partners for matching DQ alpha genes and NK/CTL activation. It is important to note that any DQ alpha match (partial or complete) will only result in an IID when there both a DQa/HLA match exists along with NK cell activation. With the exception of cases where both partners have a total (absolute DQa match and treatment requires the use of sperm from a non-matching sperm donor, about 90% of cases alloimmune implantation will have a partial match where 1: 2 embryos will match the woman’s DQa genotype and half will not. In cases of an alloimmune dysfunction (with associated NKa), treatment with IL or IVIG will in my opinion, will not protect against a matching embryo being rejected. It can only clear the NK environment for an embryo that does not match the woman’s DQa genotype. For this reason, it is my opinion that only 1 embryo should be transferred at a time because, given the fact that i:2 embryos will match, transferring >1 embryo at a time creates a risk that the matching embryo will evoke a local NKa/’cytokine response that will “muddy the water” for both. Thus, in cases of a “partial” DQa match I recommend against transferring more than a single embryo at a time.
I strongly recommend that you visit http://www.DrGeoffreySherIVF.com. Then go to my Blog and access the “search bar”. Type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.
•The IVF Journey: The importance of “Planning the Trip” Before Taking the Ride”
•Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation (COS)
•The Fundamental Requirements for Achieving Optimal IVF Success
•Use of GnRH Antagonists (Ganirelix/Cetrotide/Orgalutron) in IVF-Ovarian Stimulation Protocols.
•The Role of Immunologic Implantation Dysfunction (IID) & Infertility (IID): PART 1-Background
•Immunologic Implantation Dysfunction (IID) & Infertility (IID): PART 2- Making a Diagnosis
•Immunologic Dysfunction (IID) & Infertility (IID): PART 3-Treatment
•Thyroid autoantibodies and Immunologic Implantation Dysfunction (IID) Why did my IVF Fail
•Recurrent Pregnancy Loss (RPL): Why do I keep losing my Pregnancies
•Genetically Testing Embryos for IVF
•Staggered IVF
•Staggered IVF with PGS- Selection of “Competent” Embryos Greatly Enhances the Utility & Efficiency of IVF.
•Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation
•Preimplantation Genetic Testing (PGS) in IVF: It should be Used Selectively and NOT be Routine.
•IVF: Selecting the Best Quality Embryos to Transfer
•Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
•PGS in IVF: Are Some Chromosomally abnormal Embryos Capable of Resulting in Normal Babies and Being Wrongly Discarded?
•Immunologic Implantation Dysfunction: Importance of Meticulous Evaluation and Strategic Management 🙁 Case Report)
•Intralipid and IVIG therapy: Understanding the Basis for its use in the Treatment of Immunologic Implantation Dysfunction (IID)
•Intralipid (IL) Administration in IVF: It’s Composition; how it Works; Administration; Side-effects; Reactions and Precautions
•Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
•Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
•Should IVF Treatment Cycles be provided uninterrupted or be Conducted in 7-12 Pre-scheduled “Batches” per Year.
•A personalized, stepwise approach to IVF
•Nutritional supplements in IVF
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ADDENDUM: PLEASE READ!!
INTRODUCING SHER FERTILITY SOLUTIONS (SFS)
Founded in April 2019, Sher Fertility Solutions (SFS) offers online (Skype/FaceTime) consultations to patients from > 40 different countries. All consultations are followed by a detailed written report presenting my personal recommendations for treatment of what often constitute complex Reproductive Issues.
If you wish to schedule an online consultation with me, please contact my assistant (Patti Converse) by phone (800-780-7437/702-533-2691), email (concierge@SherIVF.com) or, enroll online on then home-page of my website (www.SherIVF.com).
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Geoff Sher
Hi. I just had an FET (donor embryos) on August 27th. The embryo was normal PGS tested, I did a biopsy to determine the window of implantation, my uterine lining was thick and looked good. I got pregnant but Friday, Sept 17th, I woke up to lots of blood and clots. My HCG was 3048 that day (Friday, Sept 17th) and I go tomorrow for another hcg test and ultrasound. I have been on a blood thinner shot through the whole process. The past few days I’ve had a headache and very weak. Did I have a miscarriage or a sub hematoma? My betas were so good—288 (sept 7th), 769 (sept 9th). What could have gone wrong? I pray I didn’t miscarry but all the signs point to yes. Thank you.
Before writing this pregnancy off, I urge you to go in and have a vaginal speculum examination and a pelvic US to try and determine the origin of the bleeding.
Geoff Sher
I just recently started my first IVF cycle after 2 unsuccessful IUIs. I’m 39.
Week after my last IUI/ week past ovulation I was put on 4mg Estrace/ day in anticipation for IVF (in case the IUI cycle does not work). I stayed on it for 3 weeks before starting IVF injections 3 days ago.
After reading more about IVF treatment I see that most doctors recommend OCP prior IVF stimulation. What is the difference between this approach vs. Estrace pill?
The concept is the same. However, In personally prefer not to use Estrace as, in part, it metabolizes to estrone and this form of estrogenn can be harmful.
Geoff Sher